Micro-implant Uprighting cantilever for the
correction of a severely rotated and angulated
mandibular canine during clear aligner treatment
Hyung-Kyu Noh, Ho-Jin Kim and Hyo-Sang Park
Department of Orthodontics, School of Dentistry, Kyungpook National University, Dalgubeol-daero, Jung-gu, Daegu,
Republic of Korea
Root movements and the rotation of a round-shaped tooth are known to be particularly challenging using clear aligners. This case
report describes effective and efficient hybrid mechanics, combining aligners and a micro-implant uprighting cantilever, to correct
a rotated and angulated mandibular canine. A 28-year-old male patient sought treatment for moderate crowding and presented
with a severely rotated and angulated right mandibular canine, which required significant root movement to correct. Despite
12.5 months of treatment using a bracketless wire in resin slots plus clear aligners, the canine rotation and angulation remained
uncorrected. Consequently, a nickel–titanium cantilever supported by a micro-implant was added to the aligner treatment. The
desired mesial-out crown rotation and distal root movement of the canine occurred in 5.5 months. Adding an auxiliary cantilever
when treating severely rotated and angulated teeth in clear aligner treatment is worthy of consideration.
(Aust Orthod J 2025; 41: 18 - 31. DOI: 10.2478/aoj-2025-0002)
Received for publication: October, 2024
Accepted: January, 2025.
Introduction fixed appliances when addressing a mild to moderate
Orthodontic treatment aims to provide aesthetically arch length discrepancy.3,12,13 The clear aligner
pleasing and functionally sound jaw–tooth correction of common problems such as the rotation
relationships.1,2 Traditionally, brackets and wires have and angulation of a tooth, especially for a round-
been the common choice of appliance.3 However, shaped tooth, is known to be challenging.10,11,13–15
wearing fixed appliances can increase the risk of tooth The accuracy of aligner therapy for canine rotation
surface decalcification and periodontal problems.4–7 is reportedly only 40%, suggesting this as a reason
Moreover, patients may experience discomfort during for an extended treatment time.10,11 A hybrid
eating and daily activities.8,9 Clear aligners offer approach using fixed appliances and clear aligners,
distinct advantages over fixed appliances, including has therefore been proposed.16,17 However, to date,
superior aesthetics, enhanced comfort, and improved evidence describing the detailed mechanics of hybrid
oral hygiene.3,8 approaches and their treatment outcomes remains
The accuracy and efficiency of aligner therapy scarce.
remain controversial.10,11 Generally, the more The present case report describes the effective and
complex the treatment case, the less satisfactory efficient treatment procedure of a severely rotated
the outcome.3,12 Currently, the overall performance and angulated mandibular canine by combining
of clear aligners is primarily comparable to that of clear aligners, a nickel-titanium (NiTi) cantilever,
18 Australasian Orthodontic Journal Volume 41 2025 ☉ Open Access. Published by Sciendo. cc BY 4.0 © 2025 Author(s). This work is licensed under
the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/)
MICRO-IMPLANT CANTILEVER FOR ROOT MOVEMENT
Figure 1. Pre-treatment records, including extraoral and intraoral photographs.
and a micro-implant. The mechanics and treatment were evident. The patient had square upper and lower
outcomes are discussed in detail using cone-beam arch forms and mild to moderate crowding (2 mm in
computed tomography (CBCT) and intra-oral scan the maxilla and 6 mm in the mandible, respectively).
models. Notably, the right mandibular permanent canine
showed a severe mesial-in rotation and a crown-distal
angulation. The Bolton’s anterior ratio was 78.9%,
Diagnosis and aetiology and the overall ratio was 93.2%, indicating that the
A 28-year-old male patient sought treatment for mandibular anterior and posterior teeth were larger
anterior dental crowding. Written informed consent than the corresponding maxillary teeth by 0.8 mm
was obtained from the patient for the use and and 1.0 mm, respectively.
publication of his records. On presentation the patient The panoramic radiograph showed a distally
was noted to have a straight facial profile (Figure 1). angulated left mandibular third molar, while the
Dentally, an Angle Class I molar relationship on the maxillary third molars had erupted in an upright
right and a mild Angle Class II tendency on the left position (Figure 2). The findings from the lateral
Australasian Orthodontic Journal Volume 41 2025 19
NOH, KIM AND PARK
Figure 2. Pre-treatment radiographic records, including panoramic and lateral cephalogram.
cephalogram indicated a Class I skeletal pattern, with Treatment alternatives
a slightly reduced mandibular plane angle (Figure 2, The first option was comprehensive fixed appliance
Table I). Additionally, the maxillary and mandibular treatment after extracting the third molars.18
incisors were retroclined. Although this plan would likely improve the
Based on these findings, the patient was diagnosed as occlusal relationship on the left side, the treatment
a hypodivergent skeletal Class I malocclusion, with a period could be extensive. Consequently, the patient
mild to moderate arch length discrepancy. declined this treatment approach.
The second option was to resolve the crowding by
Treatment objectives bonding brackets to the anterior teeth only.19 The
patient also declined this treatment approach since
The treatment goal was to resolve the crowding by he preferred aesthetically pleasing and comfortable
proclining the incisors without worsening the facial orthodontic appliances rather than conventional
profile, while preserving the molar relationships. brackets.
Finally, treatment using clear aligners was
Table I. Cephalometric measurements
considered.3,8 However, it was anticipated that aligner
Measurements Norm Pre-treatment Post-treatment therapy would pose difficulties in adjusting the right
Anterior Posterior mandibular canine.7,8 To address this, it was planned
to manage the problem by using a bracketless NiTi
SNA (°) 82.1 82.4 82.4
wire first, followed by clear aligners to detail the
SNB (°) 79.8 81.0 81.0 remaining malocclusion.20
ANB (°) 2.3 1.4 1.4
Vertical
Treatment progress
FMA (°) 23.5 21.5 21.5
NiTi wires (0.014-inch, DynaFlex, MO, USA)
Gonial Angle (°) 117.9 118.2 118.2 were bonded to the maxillary and mandibular
FH-Occ (°) 8.3 10.2 10.2 arches using flowable resin (Tetric® N-Flow, Ivoclar
Dental Vivadent, Schaan, Liechtenstein). To ensure play
U1 to FH (°) 116.2 110.9 119.1
between the wire and bracket, a lubricant was applied
on the wire before bonding. To enhance alignment,
IMPA (°) 96.3 87.5 94.6
labial proclination of the anterior teeth was generated
Interincisal angle (°) 124.1 140.1 124.8 which modified the arch form into an ovoid shape
Soft tissue (Figure 3). As treatment progressed, the archwire
Upper lip to E-line (mm) -0.8 -3.7 -4.0
bonding was continually adjusted. After eight
months, the alignment of the maxillary dentition had
Lower lip to E-line (mm) 0.5 -0.7 -2.7
improved (Figure 4). However, the distal angulation
20 Australasian Orthodontic Journal Volume 41 2025
MICRO-IMPLANT CANTILEVER FOR ROOT MOVEMENT
Figure 3. Intraoral photographs after the bonding of bracketless nickel-titanium wires.
Figure 4. Treatment progress at eight months. A, Intraoral photographs. B, Model superimposition. The white colour denotes pre-treatment, and the dark
colour represents the status at eight months. The registrations were performed on the occlusal surfaces of the first and second molars.
Australasian Orthodontic Journal Volume 41 2025 21
NOH, KIM AND PARK
Figure 5. Treatment progress at 12.5 months. A. Intraoral photographs. B. Model superimposition. The white colour denotes the model at eight months,
and the dark colour represents the 12.5 month stage. The registrations were performed on the occlusal surfaces of the first and second molars.
of the mandibular canines was evident, as the right automatically adjusted the actual planned tooth
side remained the most prominent. movement to not exceed these limits. The models
As the patient requested clear aligner treatment, in- were confirmed by a single orthodontist (H.S.P.)
house clear aligners were fabricated. After removing and printed using a fused filament fabrication type
the wires, ellipsoidal-shaped attachments were of printer with a resolution of 200 µm (DP101,
bonded directly onto the labial surface of the upper Sindoh, Seoul, Korea). A total of 18 sets of aligners
and lower dentition except for the maxillary central were fabricated by a thermoforming process (Biostar,
incisors, the maxillary canines, the maxillary and Scheu Dental, Iserlohn, Germany) and using a
mandibular second molars, and the left mandibular material sheet thickness of 0.75 mm (CA® Pro+,
second premolar. The dentition was captured using Scheu Dental, Iserlohn, Germany). The patient was
an intraoral scanner (Trios, 3Shape, Copenhagen, instructed to change aligners every week and wear
Denmark), and an orthodontic virtual setup was on a full-time basis. Interproximal enamel reduction
performed (Autolign, Diorco, Seoul, Korea). Tooth (IPR) was performed as needed. Treatment using the
movements were limited to 0.3 mm for a linear first set of aligners required 4.5 months.
movement and 3° for an angular movement for each After 12.5 months of treatment, the first course
step. The values represent the maximum accepted of clear aligners was completed (Figure 5). The
tooth movement per aligner. The setup program mandibular anterior crowding was alleviated, and
22 Australasian Orthodontic Journal Volume 41 2025
MICRO-IMPLANT CANTILEVER FOR ROOT MOVEMENT
Figure 6. Hybrid mechanics illustration. Micro-implants are denoted by circles with cross-marks. Resin-wire bonding is represented by ovals on the crown
surface. The white circles on the canine root indicate the centre of resistance. Dotted lines correspond to pre-activated cantilevers, while plain lines repre-
sent activated cantilevers. Striped arrows depict cantilever activating forces. White plain arrows show the activating force delivered to the canine. Black
bold arrows represent the reactive forces. Circular arrows denote the force moment delivered to the canine. A, Oblique view. B, Occlusal view. C, The
oblique view with aligners in place. D, The force diagram in the oblique view. E, The force diagram in the occlusal view.
the mandibular arch form had been modified into canine (Figure 7) but it still required further
an ovoid shape. IPR reduced the mandibular anterior correction. In addition, the mandibular incisors
teeth size by 1.3 mm, with a resultant Bolton anterior exhibited mild rotation. Moreover, a mild distal
and overall ratio of 76.2% and 91.8%, respectively. angulation of the left mandibular canine was also
At this stage, the rotation and angulation of the right identified. Accordingly, a new set of aligners was
mandibular canine still required improvement. applied with an additional micro-implant-supported
Hence, further refinement was planned, and an NiTi cantilever. This new auxiliary wire aimed to
additional 11 steps of aligners were prepared. The tooth correct the distal angulation by root uprighting
movement per set and the wearing protocol remained (Figure 8). A total of seven sets of aligners were
the same. However, to facilitate canine adjustment, the fabricated and worn for 2.5 months.
clear aligners were combined with a sectional wire and After 18 months, treatment was completed. A lingual
a micro-implant. The micro-implant (7 mm length, 1.3 fixed retainer was bonded between the mandibular
mm diameter at the neck and 1.2 mm diameter at the canines. A removable circumferential retainer was
apex, AbsoAnchor, SH1312-07, Dentos, Daegu, Korea) also provided for the patient.
was placed between the right mandibular first and
second premolars using a drill-free method (Figure 6),
and a 0.016-inch NiTi sectional wire (DynaFlex, MO, Treatment results
USA) was bonded onto the cervical area of the right The patient’s facial profile remained straight
mandibular canine. The free end of the cantilever (Figure 9). The molar relationships were maintained,
was attached to the head of the micro-implant when and the occlusion showed acceptable interdigitation.
activated. The treatment duration using the second set The maxillary and mandibular arches had been
of aligners was three months. changed to ovoid. The anterior crowding was
After 15.5 months of treatment, a notable change resolved. Furthermore, the rotation and angulation
was observed in the position of the right mandibular of the right mandibular canine improved (Figure 10).
Australasian Orthodontic Journal Volume 41 2025 23
NOH, KIM AND PARK
Figure 7. Treatment progress at 15.5 months. A, Intraoral photographs. B, Model superimposition. The white colour denotes the model at 12.5 months,
and the dark colour represents the 15.5-month stage. The registrations were performed on the occlusal surfaces of the first and second molars.
The panoramic radiograph showed the distal The pre- and post-treatment cone-beam computed
movement of the right mandibular canine root tomography data of the mandible were superimposed
(Figure 11). The post-treatment cephalometric using the open-source software 3D Slicer (version 5.6.0;
measurements and superimposition of the pre- and SlicerCMF, http://www.slicer.org) according to a voxel-
the post-treatment films demonstrated that incisal based registration protocol and the right mandibular
proclination occurred without compromising the canine was segmented and analysed (Figure 12). The
facial profile (Figure 11, Table I). root apex moved 3.7 mm in a disto-buccal direction
Figure 8. The additional cantilever placed on the left mandibular canine. A, Oblique view. B, Frontal view. C, Occlusal view.
24 Australasian Orthodontic Journal Volume 41 2025
MICRO-IMPLANT CANTILEVER FOR ROOT MOVEMENT
Figure 9. Post-treatment records, including extraoral and intraoral photographs.
Figure 10. Model superimposition. The yellow colour denotes the pre-treatment model, and the orange colour represents the post-treatment model. The
registrations were performed on the occlusal surfaces of the first and second molars. A, Maxillary dentition. B, Mandibular dentition. C, Oblique view.
Australasian Orthodontic Journal Volume 41 2025 25
NOH, KIM AND PARK
Figure 11. Post-treatment radiographic records, including panoramic, lateral cephalogram, and the superimposition of cephalograms taken at pre- and
post-treatment.
during treatment while the cusp tip was 1.8 mm measured by determining the rate of tooth movement
mesio-lingually moved with the centre of rotation over the treatment period. Additionally, the achieved
approximately in the middle third of the clinical crown, movements and the efficiency of the bracketless NiTi
indicating an evident root movement pattern. treatment were also evaluated. The total rotation and
Tooth movements between the treatment courses angulation achieved were 34.2° and 22.6°, respectively
were analysed using the surface registration function (Table II). Of the total movements, the aligner
of the 3D Slicer program. Since the first and second therapy accounted for 30.8° of rotation and 18.8° of
molars were not moved, their occlusal surfaces were angulation change. Specifically, a 7.4° rotation and a
used for surface registration. The planned tooth 3.3° angulation were achieved during the 4.5 months
movement was compared on virtual setups with the of the aligner-only treatment period. In contrast,
actual achieved movement. To measure the planned the hybrid approach led to a 23.4° rotation and
and achieved movement, the initial model of an 15.5° angulation change over 5.5 months. Appliance
aligner treatment course was superimposed with the accuracy and efficiency were enhanced more than
planned and achieved models, respectively. Canine two to four times using the hybrid approach.
rotation was calculated as the angle between the After one year of retention, intraoral and facial
lines connecting the mesial and distal contact points. photographs were taken (Figure 14) which showed
Similarly, mesiodistal angulation, as an indirect that the treatment outcomes remained stable.
measure of root movement, was assessed as the
angle between the facial axes of the clinical crowns
(Figure 13). Treatment accuracy was evaluated Discussion
by calculating the ratio of achieved movement To achieve a functionally and aesthetically desirable
to planned movement. Treatment efficiency was outcome, teeth should be aligned along the line of
26 Australasian Orthodontic Journal Volume 41 2025
MICRO-IMPLANT CANTILEVER FOR ROOT MOVEMENT
Figure 12. Voxel-based registration of the mandibular cone-beam computed tomography image. For simplicity, the post-treatment mandible was omitted.
The yellow canine corresponds to the pre-treatment state, while the blue canine represents the post-treatment state. The orange-coloured arrows around the
canines are the displacement vectors depicting the three-dimensional movements during treatment. A, Oblique view. B, Occlusal view.
Figure 13. Rotation and angulation measurements between the initial and the predicted or achieved models. The white model serves as the reference,
while the dark model represents either the planned or achieved state. Reference lines are depicted with plain lines, and target lines as dotted lines. Arrows
indicate the angles between the reference lines. A, Rotation. B, Angulation.
occlusion with appropriate mesiodistal angulation.1,2 by a striped arrow). This force is delivered to the
Consequently, the treatment effects of rotation and canine (denoted by a white plain arrow) at the resin
angulation control have been primary goals during attachment point. The reaction force (represented
orthodontic treatment.21–23 Clear aligner therapy by a black bold arrow) is transferred to a micro-
has become a promising treatment option but the implant. All forces have the same magnitude as F1.
moment-delivering capacity of aligners remains Consequently, by the law of equilibrium in physics,
questionable.10,11,13–15 Therefore, a hybrid approach a root distal moment M1 = F1×d is produced. Using a
combining aligners and fixed appliances has been similar logic, the crown mesial-out rotation moment
recommended for cases requiring severe tooth M2 = F2×d is predicted from the occlusal view
rotational and root movements.16,17 In the present case (Figure 6E). By using a NiTi wire, these moments
report, the detailed mechanics of a hybrid technique were delivered in a light-continuous manner, which
using CBCT and intra-oral scan data were presented is the most effective and efficient orthodontic loading
and analysed. pattern.24 However, the forces F1 and F2 exerted on
The force diagram of the treatment mechanics is the canine crown (white plain arrows) and the root
shown in Figure 6. In the oblique view (Figure 6D), distal moment M1 could lead to undesired crown
a cantilever is activated with a force F1 (indicated movement in the occlusal-lingual-mesial direction.
Australasian Orthodontic Journal Volume 41 2025 27
NOH, KIM AND PARK
Table II. The right mandibular canine movement
Bracketless NiTi First CA Set Second CA Set Third CA Set
Measurements (8 months) (4.5 months) (3 months) (2.5 months)
Rotation
Planned (°) — 32.7 29.2 13.1
Achieved (°) 3.4 7.4 15.9 7.5
Accuracy (%) — 22.5 54.4 57.2
Efficiency (°/month) 0.4 1.6 5.3 3.0
Angulation (Root movement)
Planned (°) — 20.2 17.8 10.3
Achieved (°) 3.8 3.3 9.5 6.0
Accuracy (%) — 16.1 53.1 57.8
Efficiency (°/month) 0.5 0.7 3.2 2.4
Note. CA is an abbreviation of clear alinger. The period within the parentheses denotes the treatment duration of the corresponding course of treatment. The
planned movement and accuracy for bracketless NiTi were omiited since these values were unmeasurable.
With the use of aligners, this unwanted movement hybrid method enhanced the accuracy and efficiency
can be restricted by the appliances. of root movement, the present results could not be
Using voxel-based registration of the CBCT scans of compared with other studies since quantitative
the mandibles, the total canine movement between reports focusing on root movement in the mesiodistal
pre- and post-treatment was visualised (Figure 12). direction are rare. Previous studies usually analysed
The canine root apex moved distally, while the crown incisor torque control by lateral cephalograms or
exhibited a mesial-out rotation and a slight mesial shift. molar angulation using panoramic radiographs,
The displacement vectors around the canine three- rather than CBCT.15,25,26 Moreover, while recent
dimensionally illustrated this overall movement. The aligner studies have investigated the accuracy of
movement pattern co-incided with the predictions molar angulation control using virtual models, the
identified in the force diagram in Figure 6, which results did not definitively distinguish tipping versus
implies that the required moment was transferred root movements.10,27,28 Based on current knowledge,
reliably with successful control of the side effects. this is the first clinical study presenting accuracy and
The efficacy of aligner therapy for the right efficiency data of second-order root movements based
mandibular canine was thoroughly analysed. The on CBCT and virtual models.
initial clear aligner set (using only aligners) achieved Canine rotation is an additional challenge.10,11,27–30 The
accuracies of 22.5% for rotation and 16.1% for root more severe the canine rotation, the less predictable
movement, with corresponding angular efficiencies the treatment outcome.10,14,30 Hence, it is advisable
of 1.6°/month and 0.7°/month, respectively (Table II). to use alternative methods before attempting aligner
Subsequently, the hybrid method yielded significant treatment for severe rotation exceeding 20°.11,30
improvements noted as accuracies of 55.8% for Furthermore, when severe rotation and angulation
rotation and 55.5% for root movement, along with requiring root movement co-exist in a single tooth,
angular efficiencies of 4.3°/month and 2.8°/month it may become even more complicated to resolve.31
during the last 5.5 months. Clearly, the hybrid The supplementary NiTi cantilever, supported by a
approach outperformed the conventional aligner-only micro-implant, effectively enhanced the accuracy
technique in accuracy and efficiency. Consequently, and efficiency of aligner treatment in this challenging
the treatment time was positively shortened. context. If the hybrid method had been attempted
Root movement is difficult to achieve and particularly from the start, it is likely that the total treatment
challenging using aligners.13,15,25,26 Although the time would have been shortened.
28 Australasian Orthodontic Journal Volume 41 2025
MICRO-IMPLANT CANTILEVER FOR ROOT MOVEMENT
Figure 14. One year retention records, including extraoral and intraoral photographs.
Of note, the initial bracketless NiTi wire was in premolar extraction cases, attaching a NiTi
ineffective in alleviating the mandibular crowding cantilever to the cervical portion of the first molar
(Figure 4 and Table II). The patient had a mild can provide an effective molar uprighting moment.
hypodivergent vertical skeletal pattern with good However, caution may be needed when extrapolating
molar interdigitation (Figures 1 and 2). The low the present results to a broader context. While
mandibular plane angle and the patient’s likely heavy this single clinical case demonstrated a promising
biting force may have delayed tooth movements.32 outcome, further studies with a larger sample size are
After wearing aligners, the inter-occlusal material required to generalise the findings.
might have relieved the heavy interdigitation,
consequently promoting tooth alignment.
An advantage of the hybrid technique is that the force- Conclusion
moment magnitude is easily adjustable. By extending A severely rotated and angulated right mandibular
the cantilever length through a distant placement of canine was effectively and efficiently treated using a
the micro-implant, clinicians can increase the force hybrid method that combined clear aligners and a
moment. Additionally, this approach is versatile and cantilever spring attached to a micro-implant. The
adaptable to various clinical scenarios. For example, NiTi cantilever reliably delivered a moment in a light
Australasian Orthodontic Journal Volume 41 2025 29
NOH, KIM AND PARK
continuous manner. As a result, the accuracy and 12. Papadimitriou A, Mousoulea S, Gkantidis N, Kloukos D. Clinical
effectiveness of Invisalign® orthodontic treatment: a systematic
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Conflict of interest
Health. 2014;14:1–7.
The authors declare that there is no conflict of interest. 15. Hong Y-Y, Zhou M-Q, Cai C-Y, Han J, Ning N, Kang T, et al.
Efficacy of upper-incisor torque control with clear aligners: a
retrospective study using cone-beam computed tomography. Clin
Oral Investig. 2023;27:3863–73.
Corresponding author
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Hyo-Sang Park, DDS, PhD, Professor and Chair, Orthod. 2017;23:65–75.
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Kyungpook National University, Daegu, Korea, Tel: Orthod. 2017;87:809–15.
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